A 67-year-old African American male is transported via ambulance from a primary care clinic to
the nearest emergency room (ER) with a severely elevated blood pressure of 228/120
accompanied by confusion.
The emergency medical responders report that the patient has a long-standing history of
uncontrolled hypertension (HTN), type 2 diabetes mellitus (DM), and hypercholesterolemia. He
was seen by his primary care nurse practitioner (NP) who noted that the patient had an elevated
blood pressure of 230/120 associated with acute confusion. An ambulance was called to
transport the patient to the nearest ER.
History of Present Illness
The patient’s wife denies that the patient experienced weakness, paresis, or paralysis of
extremities, dysarthria, aphasia, or other signs that may indicate a stroke, but notes that the
patient started acting “strangely” at approximately 8pm the night before admission. This morning
he was confused about the day and year, and forgot many of the details of his daughter’s recent
wedding. She was concerned so she took him to the primary care office, where the NP called
911. She reports there is no recent history of trauma, falls, or substance abuse. She endorses that
the patient has hypertension and diabetes, as reported by the primary NP, and denies any history
of cancer or heart disease. She also reports that he stopped taking his blood pressure medications
approximately 6 months ago because they caused excessive fatigue. She is unsure if he is taking
his other prescribed medications.
Past Medical History: HTN, DM, Type II, High cholesterol
Past Surgical History: Per wife and the EMR, patient has never had surgery
Social History: Patient’s wife reports he has never smoked, does not drink, does not use drugs
Medications:
• No known allergies
• Lipitor 10mg PO daily
• Metformin 500mg PO BID
• Per EMR: He is prescribed Amlodipine 10mg PO daily and Toprol 50mg PO daily, but
has not filled his prescriptions for the last 6 months
General Survey The patient’s vital signs on admission to the ER are:
BP 228/116 mmHg
HR: 78 beats per minute, normal sinus rhythm on the monitor
RR: 18 breaths/min
O2 sats: 96% on room air
He is lethargic but easily arousable, disoriented to time and place, and therefore unable to give a
reliable history. Data is gathered from his wife and the electronic medical record (EMR).
Review of Systems
The patient is unable to answer all of the questions; some of the information is obtained from the
patient’s wife.
Constitutional: denies fever, chills
Cardiovascular: denies chest pain, chest pressure, SOB, palpitations
Pulmonary: denies SIB
GI: denies abdominal discomfort, unable to determine last bowel movement
GU: denies burning with urination
Musculoskeletal: denies pain of extremities
Neurological: the patient is unable to provide a timeline as to the onset of confusion; per wife the
patient started acting “strangely” after dinner – “quiet, non-communicative, not answering
questions – said he did not feel well, but would not elaborate”. This morning his wife was
concerned when he appeared dazed and confused. He was disoriented to day and time. Wife
reports acute changes to short – and -long term memory.
Endocrine: denies thirst, excessive urination or excessive hunger, does not check blood glucose
at home.
Physical Examination
Vital signs
Repeat blood pressure is 200/120 mmHg in both right and left arms
Temp 36.0 C oral
HR 78 beats per minute
RR 16 breaths per minute
O2 sats 95% on room air
Weight 90 kg
Height 5’10”
BMI 28.1
Constitutional: Obese male, appears stated age, lethargic, disoriented to time and place, oriented
to person, arouses easily, able to answer simple questions with a “yes” or “no”.
HEENT: Normocephalic, anicteric, fundoscopic examination reveals exudates and cotton wool
spots, consistent with grade III retinopathy, no carotid bruits, no thyromegaly, or thyroid
nodules.
Cardiovascular: S1, S2, no murmurs, no gallops, no rubs, +displaced PMI. Pulses are present
bilaterally +2+2 right and left dorsalis pedis and posterior tibial pulses.
Pulmonary: Respirations are even and unlabored, breath sounds are clear and equal throughout.
Gastrointestinal: Normoactive bowel sounds, abdomen is soft, non-tender, non-distended, no
hepatosplenomegaly, + left epigastric abdominal bruit – systolic diastolic bruit.
Skin: Warm and dry, no rashes or lesions noted.
Musculoskeletal: Nontender spine; +systolic-diastolic bruit – located at the mid to lower left of
the spine.
Neurological: Limited neurological examination due to the patient’s inability to follow
commands. Cranial nerves II-XII intact, however, unable to examine extraocular movements
due to the patient being unable to follow commands; otherwise grossly non-focal, able to move
both arms and legs; no facial asymmetry, no dysarthria.
Preliminary Diagnostic Results
12-lead ECG reveals NSR of 78 beats per minute; PR interval 0.14, QRS interval 0.06; QT
interval 0.40 with left ventricular hypertrophy.
CXR demonstrates borderline cardiac enlargement; negative for a widened mediastinum.
NECT: negative for bleeding; diffuse white matter changes consistent with cerebral
encephalopathy.
Laboratory Results
Today One Year Ago Troponin 0.01 mg/mL
Na 140 mEq/L 136
K 4.4 mEq/L 4.2
Cl 105 mEq/L 107
CO2 24 mEq/L 21
Total cholesterol 200 mg/dL 261
LDL 139 mg/dL 156
HDL 32 mg/dL 25
Triglycerides 300 mg/dL 402
BUN 40 mg/dL 23
Creatinine 2.5 mg/dL 1.0
WBC 6,900 cells/uL 7,600
Hbg 12.7 g/dL 13.8
Hct 35.5% 38.5
Glucose 92mg/dL 105
HgbA1c 8.5 7.0
GFR 36 cc/min 87
Urinalysis: specific gravity 1.020, pH 5.0, color clear, protein 100 mg/dL,
leukocyte esterase negative, nitrate negative, ketones negative, red blood cells
negative.
Toxicology screen: negative
Case Study Questions
1. What are the pertinent positive of this case?
2. What are the significant negatives of this case?
3. What laboratory and diagnostic testing should be ordered? Use national guidelines to support
your responses.
4. Provide a case analysis and formulate your diagnosis and treatment plan. Provide a minimum
of 3 differential diagnoses and explain each. Use national guidelines to support your responses.
5. Follow APA, 7th edition guidelines.
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